Privacy Practice Notice and Forms

This notice is for members of BCBSIL Group Plans, Individual and Family Plans and Medicare Plans.  

Medicaid plan members have their own Privacy Practices Notice. Go to:  

Use the forms below if you are covered by a BCBSIL health plan through your employer, or if you are covered by a BCBSIL Individual or Medicare health plan.

Use this form to ask BCBSIL to share your protected health information (PHI) with a certain person or entity.

Use this form to ask BCBSIL for a copy of your PHI records.

Use this form to ask BCBSIL to update your PHI.

Use this form to get a record of how BCBSIL shared your PHI.

If you had a request to update your PHI denied by BCBSIL, use this form. You can ask that the original request and the denial be attached to future disclosures of your PHI.

Do you feel your life could be in danger if you get mail at your current address? Use this form to ask BCBSIL to restrict your PHI and communicate with you at an alternate location.

Use this form to ask BCBSIL to restrict your PHI from being used or shared with another person or non-covered entity under HIPAA.

Use this form to file a privacy or security complaint with BCBSIL.

Medicaid plan members have their own privacy forms. Go to: